ArticlePDF Available

Abstract and Figures

BACKGROUND: The advanced periodontal disease is characterised by a strongly pronounced loss of attachment and reduction of the alveolar bone support, which leads to luxation, migration of the teeth, functional discomfort and poor facial aesthetics. CASE PRESENTATION: The aim of this paper is to present the case of a 26-year-old female patient, registered at the Clinic of Periodontology with highly expressed gingivitis, unsatisfactory periodontal status, presence of diastemas between the frontal teeth and attachment loss of 5-6 millimetres in different areas. We conducted a thorough classic periodontal treatment, as well as training for proper maintenance of oral hygiene, with frequent professional oral-prophylactic sessions, complemented with orthodontic treatment. Fixed orthodontic appliances were installed, and mild forces were applied for gradual levelling of the teeth, with constant control of the periodontal status. After 20 months of treatment, the patient was in retention. CONCLUSION: Orthodontic therapy of periodontally-affected teeth can begin only after exhaustive administration of a periodontal treatment. Orthodontic treatment as an addition to the periodontal restoration must be gradual with mild forces for an optimal dental response, thus helping to improve function, facial aesthetics and psychological confidence of adult patients.
Content may be subject to copyright.
_______________________________________________________________________________________________________________________________
Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2343
ID Design Press, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2019 Jul 30; 7(14):2343-2349.
https://doi.org/10.3889/oamjms.2019.629
eISSN: 1857-9655
Dental Science - Case Report
Orthodontic Treatment of a Periodontally - Affected Adult Patient
(Case Report)
Stevica Ristoska1*, Biljana Dzipunova2, Emilija Stefanovska1, Vasilka Rendzova3, Vera Radojkova-Nikolovska1, Biljana
Evrosimovska4
1Department of Oral Pathology and Periodontology, Faculty of Dental Medicine, Ss Cyril and Methodius University of Skopje,
Skopje, Republic of Macedonia; 2Department of Orthodontics, Faculty of Dental Medicine, Ss Cyril and Methodius University
of Skopje, Skopje, Republic of Macedonia; 3Department of Restorative Dentistry, Faculty of Dental Medicine, Ss Cyril and
Methodius University of Skopje, Skopje, Republic of Macedonia; 4Department of Oral and Maxillofacial Surgery, Faculty of
Dental Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
Citation: Ristoska S, Dzipunova B, Stefanovska E,
Rendzova V, Radojkova-Nikolovska V, Evrosimovska B.
Orthodontic Treatment of a Periodontally - Affected Adult
Patient (Case Report). Open Access Maced J Med Sci.
2019 Jul 30; 7(14):2343-2349.
https://doi.org/10.3889/oamjms.2019.629
Keywords: Adult orthodontics; Periodontal health;
Orthodontic appliances; Periodontal disease; Root
resorption; Orto-perio treatment
*Correspondence: Stevica Ristoska. Department of Oral
Pathology and Periodontology, Faculty of Dental
Medicine, Ss Cyril and Methodius University of Skopje,
Skopje, Republic of Macedonia. E-mail:
stevica_rist@yahoo.com
Received: 03-Jun-2019; Revised: 15-Jul-2019;
Accepted: 17-Jul-2019; Online first: 20-Jul-2019
Copyright: © 2019 Stevica Ristoska, Biljana Dzipunova,
Emilija Stefanovska, Vasilka Rendzova, Vera Radojkova-
Nikolovska, Biljana Evrosimovska. This is an open-access
article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International
License (CC BY-NC 4.0)
Funding: This research did not receive any financial
support
Competing Interests: The authors have declared that no
competing interests exist
Abstract
BACKGROUND: The advanced periodontal disease is characterised by a strongly pronounced loss of attachment
and reduction of the alveolar bone support, which leads to luxation, migration of the teeth, functional discomfort
and poor facial aesthetics.
CASE PRESENTATION: The aim of this paper is to present the case of a 26-year-old female patient, registered
at the Clinic of Periodontology with highly expressed gingivitis, unsatisfactory periodontal status, presence of
diastemas between the frontal teeth and attachment loss of 5-6 millimetres in different areas. We conducted a
thorough classic periodontal treatment, as well as training for proper maintenance of oral hygiene, with frequent
professional oral-prophylactic sessions, complemented with orthodontic treatment. Fixed orthodontic appliances
were installed, and mild forces were applied for gradual levelling of the teeth, with constant control of the
periodontal status. After 20 months of treatment, the patient was in retention.
CONCLUSION: Orthodontic therapy of periodontally-affected teeth can begin only after exhaustive administration
of a periodontal treatment. Orthodontic treatment as an addition to the periodontal restoration must be gradual
with mild forces for an optimal dental response, thus helping to improve function, facial aesthetics and
psychological confidence of adult patients.
Introduction
Dentofacial aesthetics is the primary
motivational factor in adolescent and adult population
for conducting orthodontic treatment. The number of
adult patients undergoing orthodontic therapy has
constantly been rising in the last 2-3 decades [1]. 20-
25% of orthodontic patients are adults, and there is an
increasing trend in the number of adult patients as a
result of their increased awareness of the importance
of their oral health and their need for a better aesthetic
appearance [2]. The main driving factor in adults is to
improve their dental and facial appearance [3], [4].
Twelve per cent of adults seeks orthodontic treatment
to prevent occurrence or progression of periodontal
disease [5].
Adult patients are divided into two different
groups: 1st group-young adults (under 35 years of
age, usually after their 20s) who were in need but
could not receive orthodontic treatment during the
adolescent period. The 2nd group consists of mature
patients in their 40s-50s who have other dental
problems and need orthodontic treatment as a part of
a larger therapeutic plan that includes numerous
dental disciplines [6].
Studies suggest that orthodontic therapy
providing good dental aesthetics also has a strong
impact on the psychosocial aspect of the patient's life
[7]. It has been confirmed that almost 80% of patients
accept treatment because of the aesthetic aspect
Dental Science - Case Report
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
2344 https://www.id-press.eu/mjms/index
rather than dental health and function [8].
Today, orthodontic treatment can be
justified as a part of periodontal therapy if it is used to
reduce plaque accumulation, correct abnormal
gingival and osseous forms, improve aesthetics and
facilitate prosthetic replacement [9].
Age, per se, is not a contraindication to
orthodontic treatment. Fact is that the tissue’s
response to orthodontic forces, cell mobilisation and
conversion of collagen fibres is much slower in adults.
Adult bone is less reactive to orthodontic force. There
is a great risk of marginal bone loss and loss of
attachment with mild gingival infection [2]. Dental
response to orthodontic forces is slower in adults, but
the teeth are moving in the same manner regardless
of age.
A large number of adult patients have
problems with malocclusion due to having neglected
their periodontal health, leading to a loss of bone
substrate around the teeth, resulting in pathological
migration, rotations, tipping and extrusions of the
teeth. Special attention should be given to the
periodontal status of adult patients since most of them
already suffer from periodontal disease. However,
orthodontic treatment is no longer a contraindication in
the therapy of advanced periodontal disease. This
treatment can help rescue and restore the
deteriorated dentition [10].
The advanced periodontal disease is
characterised by a strongly pronounced loss of
attachment, reduction of alveolar bone support,
leading to tooth mobility, pathological migration, tooth
extrusion, tipping, loss of contact point, presence of
spacing between the teeth and marginal gingival
recession. In many cases, this functional discomfort is
accompanied by a pronounced poor aesthetic in the
anterior dental region, which is reflected in the entire
face [10].
The management of adult orthodontic
patients with severe bone loss continues to present a
challenge. Well-aligned dentition may be more
conducive to periodontal health, than a crowded
dentition and malocclusion. It has been widely
believed that appropriately applied orthodontic forces
do not damage the periodontium. On the contrary,
they can support the periodontal tightness, but oral
hygiene is obligatory.
Orthodontic therapy of the periodontally-
affected teeth can begin only after a thoroughly
performed periodontal treatment in multiple sessions
when the periodontal inflammation would be
eliminated. In a motivated patient who responds well
to initial periodontal therapy, orthodontic treatment
provides positive, satisfactory aesthetical and
functional results, and a good long-term prognosis.
Maintaining high-level oral hygiene at home, as well
as frequent professional visits is very important
(imperative) during and after the end of an active
orthodontic therapy [11]. This can be supported by
findings of Mattingly [12], Paolantonio [13], Sallum
[14] and Perinetti [15], which confirm that long-term
fixed appliances can contribute to unwanted, but
predictable qualitative alterations in the subgingival
bacterial biofilm that become progressively pathogen
with time, if oral hygiene is not well. The combination
of orthodontic intrusion and periodontal treatment in
animals with good oral hygiene and healthy tissue
showed an improvement in the periodontal condition
[16]. A reduction of probing depth in bone defects
following tooth extrusion can also be achieved [17].
General factors as morphology and deepness of
defects, oral hygiene, plaque control and patient
compliance, can strongly affect the predictability of
periodontal regeneration [18].
The goal of the paper is to show the
possibilities in the therapy of a periodontally-
compromised adult patient, patient selection,
preparations and stages of therapy, prerequisites for
success and further recommended surgical
procedures.
Case History
A 26 years old female patient visited the Clinic
of Oral pathology and periodontology, complaining
about the wide spaces between her teeth, strongly
expressed gum bleeding and tooth luxation in the front
region. She complained of poor self-esteem and bad
social life. She was treated at our clinic for the first
time when she was 17. After a long period of time
without any therapy, she returned with those
problems.
There was no significant medical history of
any disease which may have contributed to
periodontal disease. However, she noted that one of
the parents had early teeth loss, and the two younger
sisters had a problem with bleeding from the gingiva.
Figure 1: Presence of diastema between upper left central and
lateral incisors
Upon clinical examination, we noticed that
she had an asymmetrical face and a convex facial
Ristoska et al. Orthodontic Treatment of a Periodontally - Affected Adult Patient (Case Report)
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2345
profile. The lips were incompetent, and she was
showing hyperactivity of the lower and upper lip while
closing the lips. There were also generalised deposits
of dental plaque and calculi due to poor oral hygiene.
No active caries lesions were present. The pocket
depth ranged from 3-6 mm in different areas of
dentition. Her periodontal condition was poor, with
gingival recession in many areas, especially in the
lower incisor region, presence of wide spaces
between the teeth, especially in the lower jaw as well
as in the upper left central and lateral incisor (Figure
1, Figure 2 and Figure 3).
Figure 2: Upper jaw from the occlusal side
Before starting with the therapy, the patient
was informed about the complications that could occur
during the orthodontic treatment such as the
possibility of root resorption, more bone loss around
the teeth and worsening of periodontal disease, as
well as the need to maintain oral hygiene at the
highest level. Informed consent was obtained from
her.
Figure 3: Presence of wide spaces between the teeth in the lower
jaw and migration of the teeth
The periodontal treatment was started in
September 2015. We proceeded with a thorough
conservative periodontal treatment consisting of the
complete elimination of dental calculus and biofilm.
After that, scaling and root planning were conducted
in all 4 quadrants during several sessions. In the initial
phase of the therapy, due to the presence of a severe
expressed gingival inflammation, antibiotic therapy
was included as an addition to the conservative
treatment. In the whole duration of the process, the
patient was trained for proper maintenance of oral
hygiene at home.
This process was ongoing for over a year,
with frequent professional oral-prophylactic sessions
every 3-4 months. Over a year of observation before
the installation of orthodontic appliances helped us
judge the patients cooperation in oral hygiene
maintenance until it was made sure that it was
possible to start with orthodontic therapy. Ensuring
that the movement of the teeth would occur in a
healthy periodontal environment was of paramount
importance before proceeding with the therapy. If this
had not been done, orthodontically-applied forces
could enhance the gingival inflammation and destruct
the supporting tissues [19].
Figure 4: X-Ray before the start of the therapy
At the beginning of the periodontal treatment,
an X-Ray was made for precise detection of
periodontal status and osseous defects (Figure 4).
Figure 5: An upper fixed orthodontic appliance was placed
In January 2017, an upper fixed orthodontic
appliance was applied (Figure 5). 022 slot SWA was
used, alignment and levelling of the teeth were with
light forces using NiTi wires. To avoid the incisor root
desorption, we applied low intrusion forces (5-15
gr/tooth). In the second phase we used elastic bands
Dental Science - Case Report
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
2346 https://www.id-press.eu/mjms/index
with long filaments to close the spaces and make
good contacts.
Figure 6: Applied lower fixed orthodontic appliance
After six months, the lower fixed orthodontic
appliance was applied (Figure 6) and 022 slot SWA
was used, alignment and levelling were achieved with
light forces using NiTi wires and elastic bands with
long filaments.
Figure 7: Dental status at the end of the 1st year of orthodontic
therapy
At the end of first year of orthodontic therapy,
the oral situation was pleasant and as expected
(Figure 7 and Figure 8).
Figure 8: Improvement of the overall oral situation
After 20 months of active treatment, the
patient is in retention (Figure 9, 10, 11, and 12).
Figure 9: Dental status after 20 months of orthodontic therapy
Continuing monitoring of oral hygiene and
administration of Gengigel (0.8% hyaluronic acid) to
improve the attachment, was coordinated by the
parodontologyst.
Figure 10: Satisfactory results after 20 months
Treatment results
After an active orthodontic phase of 20
months, the spaces between her upper and lower
incisors were closed; the incisors were retracted to
achieve acceptable overjet and overbite relation.
Clinical examination revealed well-aligned arches, a
harmonious occlusion and good periodontal health.
Improved lip relationship, smile and facial esthetics
were achieved. Patient’s cooperation in oral hygiene
maintenance was satisfactory. The patient was very
satisfied with the treatment and had improved
psychosocial confidence.
Figure 11: Satisfactory facial appearance
Ristoska et al. Orthodontic Treatment of a Periodontally - Affected Adult Patient (Case Report)
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2347
Orthodontic intrusion and levelling of
periodontally-migrated teeth changed the topography
of the original horizontal defects.
The therapeutic procedure at this patient will
continue with surgical treatment of the deep
periodontal defects in the frontal area and lateral
regions of the upper jaw, as well as overlapping the
recessions of the lower frontal teeth.
Figure 12: X-Ray at the end of the orthodontic treatment
Discussion
The number of adult patients in need of
orthodontic treatment has increased in recent years.
The patient must be evaluated for systemic diseases,
perio-restorative problems, TMJ disorders and
vulnerability to root resorption. The biomechanics
must be customised for the individual treatment
requirement. It has been found that the expectations
of adult patients are usually high, and the limitations of
orthodontic treatment must be explained at the
beginning of treatment to arrive at realistic treatment
objectives [2]. Thomson in his population-based
longitudinal study found that periodontal attachment
loss and gingival recession was not significantly
different between the orthodontic treatment group and
non-orthodontic treatment group [20]. However, Hye-
Young Sim et al. investigated the association between
orthodontic treatment and periodontitis in a nationally
representative sample of the Korean population. The
results indicated that orthodontic treatment was
associated with decreased prevalence of periodontitis
[21]. The importance of periodontal health has
increased as the number of adult orthodontic patients
has increased.
Orthodontics can serve as an adjunct to
periodontal treatment procedures to improve oral
health in a number of situations. Achieving esthetically
acceptable results in periodontally-compromised
patients requires various teeth movements, which can
also help control the periodontal breakdown and
restore good oral function [22]. The fixed appliance
allows easy splinting of teeth to achieve stable
anchorage [23], so force magnitude must be reduced
to minimum. According to Deppa [24], teeth alignment
can be achieved by orthodontic soft aligners in
periodontally involved teeth.
A viable periodontal ligament is important for
cell proliferation on the application of the orthodontic
forces. There is reduction in periodontal ligament
vascularity with ageing and insufficient source of
preosteoblasts. It is obligatory to use lighter,
controlled force levels in adults because the greater
forces result in vascular compression and necrosis of
blood vessels of periodontal ligament. There is a risk
of iatrogenic damage to the periodontium with
uncontrolled forces, and thus it is important to keep
the periodontal status under control during treatment.
Adults are more vulnerable to root resorption on
application of orthodontic force. Light continuous force
must be applied to minimise the risk of root resorption,
and the patient must be informed of the potential risks
before starting the treatment [1], [2], [9]. Tulloch [23]
suggested that tooth movement can be undertaken 6
months after completion of active periodontal
treatment if there is sufficient evidence of complete
resolution of inflammation.
The most important factor in the initiation,
progression and recurrence of periodontal problems is
the presence of microbial plaque. Inadequate
maintenance of oral hygiene during orthodontic
treatment increases the risk of developing gingival
inflammation. There is much evidence of increased
count of Lactobacillus in saliva after orthodontic
braces placement [25]. Many clinical studies have
reported that plaque accumulation and gingivitis
increased during orthodontic treatment [26]. The
composition and types of oral bacteria were altered as
a result of orthodontic treatment [27], [28]. Recent
animal studies suggested that orthodontic tooth
movement had a synergistic effect on the
periodontium by increasing the presence of Il-1 β and
TNF-α [29].
The surgical phase consists of techniques
performed for pocket therapy and the correction of
related morphological problems, namely,
mucogingival defects. The purpose of surgical pocket
therapy is to eliminate the pathological changes in the
pocket walls, to create a stable, easily maintainable
state, and if possible, to promote periodontal
regeneration. A critical aspect of periodontal
regeneration is the stimulation of a series of events
and cascades, which can result in the coordination
and completion of integrated tissue formation [30].
Many approaches have been used involving
polypeptide growth and differentiation factors,
extracellular matrix proteins and proteins involved in
bone metabolism. These materials are largely
physiological molecules or molecules released by
cells which regulate processes in wound healing.
These growth factors, primarily secreted by
macrophages, endothelial cells, fibroblasts and
platelets, include platelet-derived growth factor
(PDGF), bone morphogenetic protein (BMP) and
transforming growth factor (TGF). These biological
mediators have been used to stimulate periodontal
Dental Science - Case Report
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
2348 https://www.id-press.eu/mjms/index
wound healing, promoting migration and proliferation
of fibroblasts (for periodontal ligament formation) or
promote the differentiation of cell to become
osteoblasts, thereby favouring bone formation [31].
Guided tissue regeneration (GTR), demineralised
freeze-dried bone allograft, or a combination of these,
are considered to be the most predictable
regenerative procedures for achieving favourable
treatment outcomes in periodontally-affected adult
patients. These findings were further supported by
many researchers who indicated that periodontal bone
grafts consistently led to better bone fill of the defect,
than the non-grafted controls. Histological analyses of
cementum regeneration in animals demonstrated that
regenerative treatment with bone grafting leads to
some degree of regenerated cement, periodontal
ligament and bone [32]. Regenerative procedures
have a more predictable positive response in deep
and narrow defects rather than shallow ones.
A multidisciplinary approach is always
necessary to treat complex dental and periodontal
problems, and there cannot be a better example than
ortho-perio interaction. Periodontists should recognise
the importance of orthodontic intervention in achieving
results unattainable with periodontal therapy alone
[33], [34], [35]. Adult orthodontic treatment can help
prevent or improve periodontal problems, can help
prevent and reduce further bone loss around teeth,
improve the dentist’s chances to restore missing
teeth, adjust aesthetics to get a better smile and facial
appearance, enhance function of teeth, increase self-
confidence and self-esteem, and finally, improve
overall oral health.
In conclusion, patient education, motivation,
enhanced oral hygiene maintenance and regular
periodontal care are essential during orthodontic
treatment. Orthodontic therapy in periodontally-
compromised patients requires extensive periodontal
care, before, during and after the treatment. In some
cases, periodontal restorative surgery may be
required for sealing the pockets. In order to prevent
relapse of the teeth to their previous state and ensure
long-term results, the appliance of lingual bonded
retainers is recommended. Interdisciplinary approach
complemented by patient education, cooperation and
good oral hygiene, will transform a patient with an
unattractive dentition due to periodontal breakdown
into a person with a good occlusion and a radiant
smile. Adult patients must undergo regular oral
hygiene procedures and periodontal maintenance to
maintain healthy gingival tissue during active
orthodontic therapy.
References
1. Proffit W. Special confiderations in comprehensive treatment for
adults. In: Proffit W, Fields HW, eds. Contemporary Ortodontics,
5rd ed. St. Louis, Mo: Mosby, 2012.
2. Bagga DK. Adult Orthodontics Versus Adolescent Orthodontics:
An overview. J Oral Health Comm Dent. 2010; 4(2):42-47.
https://doi.org/10.5005/johcd-4-2-42
3. McKiernan EX, McKiernan F, Jones Ml. Psychological profiles &
motives of adults seeking orthodontic treatment. Int J Adult Orthod
Orthognath Surg. 1992; 7:187-198.
4. Claman L, Alfaro MA, Mercado AM. An interdisciplinary
approach for improved esthetic results in the anterior maxilla. J
Prosthet Dent. 2003; 89:1-5. https://doi.org/10.1067/mpr.2003.5
PMid:12589277
5. Perrigaard J, Blixencrone-Moller T. Why do adults seek
orthodontic treatment. InProceedings of 64th Congress of
European Orthodontic Society, London 1988 (p. 61A).
6. Proffit W, Fields HW, eds. Contemporary Ortodontics, 5rd ed. St.
Louis, Mo: Mosby; 2012.
7. Gazit-Rappaport T, Haisraeli-Shalish M, Gazit E. Psychosocial
reward of orthodontic treatment in adult patients. Eur J Orthod.
2010; 32(4):441-6. https://doi.org/10.1093/ejo/cjp144
PMid:20089570
8. Brown DF, Moerenhout RG. The pain experience &
psychological adjustment to orthodontic treatment of
preadolescents, adolescents & adults. Am J Orthod Dentofacial
Orthop. 1991; 100(4):349-56. https://doi.org/10.1016/0889-
5406(91)70073-6
9. Newman MG, Takel HH, Klokkevold PR, Caranza FA.
Carranza's Clinical Periodontology, 10th ed. Noida Saunders,
Reed Elsevier India Private Lmt, 2006, p.856-70.
10. Xingme Fenga; Tomoko Obab; Yasuo Obac; Keiji Moriyamad.
An Interdisciplinary Approach for Improved functional and esthetic
Results in a Periodontally Compromised Adult Patients. Angle
Orthod. 2005; 75:1061-1070.
11. Meeran NA, Parveen MJ. The scope and limitations of adult
orthodontics. Indian Journal of Multidisciplinary Dentistry. 2011;
2(1):383-87.
12. Mattingly JA, Sauer GJ, Yancey JM, Arnold RR. Enhancement
of Streptococcus mutans colonization by direct bonded orthodontic
appliances. J Dent Res. 1983; 62:1209-11.
https://doi.org/10.1177/00220345830620120601 PMid:6361082
13. Paolantonio M. et all. Site-specific subgingival colonization by
actinobacillus actinomycetemcomitans in orthodontic patients. Am
J Orthod. 1999; 115:423-8. https://doi.org/10.1016/S0889-
5406(99)70263-5
14. Sallum EJ et all. Clinical and microbiologic changes after
removal of orthodontic appliances. Am J Orthod. 2004; 126:363-6.
https://doi.org/10.1016/j.ajodo.2004.04.017
15. Perinetti G et all. Longitudinal monitoring of subgingival
colonization by actinobacillus actinomycetemcomitans and
crevicular alkaline phosphatise and aspartate aminotransfere
actities around orthodontically treated teeth. J Clin Periodontol.
2004; 31:60-7. https://doi.org/10.1111/j.0303-6979.2004.00450.x
16. Melsen B. Tissue reaction following application of extrusive and
intrusive forces to teeth in adult monkeys. Am J Orthod. 1986;
6:469-75. https://doi.org/10.1016/0002-9416(86)90002-3
17. Michelogiannakis D, Makou M, Madianos PN, Rossouw P.
Orthodontic tooth movement in relation to angular bony defects.
Australasian Orthodontic Journal. 2017; 33(2):220-235.
18. Panwar M, Jayan B. Combined periodontal and orthodontic
treatment of pathologic migration of anterior teeth. MJAFI. 2010;
66:67-9. https://doi.org/10.1016/S0377-1237(10)80100-5
19. Carasol M, Liodra JC, Fernandez-Mesequer A, et al.
Periodontal conditions among employed adults in Spain. J Clin
Periodontol. 2016; 43:548-556. https://doi.org/10.1111/jcpe.12558
PMid:27027396
20. Thomson W. Orthodontic treatment outcomes in the long term:
findings from a longitudinal study of New Zealanders. Angle
Orthod. 2002; 72:449-455.
Ristoska et al. Orthodontic Treatment of a Periodontally - Affected Adult Patient (Case Report)
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2349
21. Sim HY, Kim HS, Jung DU, Lee H, Lee JW, Han K, Yun KI.
Association between orthodontic treatment and periodontal
diseases: Results from a national survey. The Angle Orthodontist.
2017; 87(5):651-7. https://doi.org/10.2319/030317-162.1
PMid:28686092
22. Zachrisson BU: Orthodontics and periodontics. In: Lindhe J,
Lang NP. Clinical periodontology and implant dentistry. 6th ed,
Oxford: Blackwell Munksgaard; 2015.
23. Tulloch JF. Contemporary orthodontics. In: Proffit WR, Fields
HWJr. Contemporary orthodontics. Louis Mosby; 2012
24. Deppad, Mehta DS, Puri VK, ShettyS. Combined periodontic-
orthodontic-endodontic interdisciplinary approach in the treatment
of periodontally compromised tooth. J Indian Soc Periodontol.
2010; 14:139-43. https://doi.org/10.4103/0972-124X.70837
PMid:21691554 PMCid:PMC3110470
25. Chaitanya K, Reddy M , Sreekanth C , Reddy V , Kumar L ,
Praveen Raj K. Orthodontic Tooth Movements and its Effects on
Periodontium. Int J Dent Med Res. 2014; 1(4):119-23.
26. Glans R, Larsson E, Ogaard B. Longitudinal changes in
gingival condition in crowded and noncrowded dentitions subjected
to fixed orthodontic treatment. Am J Orthod Dentofacial Orthop.
2003; 124:679-682. https://doi.org/10.1016/j.ajodo.2003.05.001
PMid:14666081
27. Petti S, Barbato E, Simonetti DAA. Effects of orthodontic
therapy with fixed and removable appliances on oral microbiota: a
six-month longitudinal study. New Microbiol. 1997; 20:55-62.
28. Ristic M, Svabic MV, Sasic M, Zelic O. Clinical and
microbiological effects of fixed orthodontic appliances on
periodontal tissues in adolescents. Orthod Craniof Res. 2007;
10:187-195. https://doi.org/10.1111/j.1601-6343.2007.00396.x
PMid:17973685
29. Boas Nogueira AV, Chaves de Souza JA, Kim YJ, Damiao de
Sousa-Neto M, Chan Cirelli C, Cirelli JA. Orthodontic force
increases interleukin-1β and tumor necrosis factor-α expression
and alveolar bone loss in periodontitis. J Periodontol. 2013;
84:1319-1326. https://doi.org/10.1902/jop.2012.120510
PMid:23205916
30. Cochran DL, Wozney JM. Biological mediators for periodontal
regeneration. Periodontology 2000. 1999; 19(1):40-58.
https://doi.org/10.1111/j.1600-0757.1999.tb00146.x
31. Gorbunkova A, Pagni G, Brizhak A, Farronato G, Rasperini G.
Impact of orthodontic treatment on periodontal tissues: a narrative
review of multidisciplinary literature. International journal of
dentistry. 2016; 2016. https://doi.org/10.1155/2016/4723589
PMid:26904120 PMCid:PMC4745353
32. Rabie AB, Gildenhuys G, Boisson M. Management of patients
with severe bone loss: bone induction and orthodontics. World J
Orthod. 2001; 2:142-53.
33. Han JY. A comparative study of combined periodontal and
orthodontic treatment with fixed appliances and clear aligners in
patients with periodontitis. Journal of periodontal & implant science.
2015; 45(6):193-204. https://doi.org/10.5051/jpis.2015.45.6.193
PMid:26734489 PMCid:PMC4698945
34. Zasciurinskiene E, Rune Lindsten R, Christer Slotte C, Bjerklin
K. Orthodontic treatment in periodontitissusceptible subjects: a
systematic literature review. Clin Exp Dent Res. 2016 Nov;
2(2):162-173. https://doi.org/10.1002/cre2.28 PMid:29744163
PMCid:PMC5839229
35. Zascinrinskiene E, Lindsten R, Baseviciene N, Slote C.
Orthodontic treatment simultaneous to or after periodontal cause
related treatment in periodontally susceptible patients. Journal of
Clinical Periodontology. 2017; 45(2):213-24.
https://doi.org/10.1111/jcpe.12835 PMid:29106749
... Periodontitis is a complex clinical entity, determined by the nature of the biofilm, individual risk factors and host defence [16]. In this respect, the importance of bacterial colonisation for the planning and implementation of orthodontic therapy cannot be neglected and of clinical relevance due to the increasing number of adult orthodontic treatments [17]. The gram-negative periodontal pathogens, Aggregatibacter actinomycetemcomitans (A. ...
Article
Full-text available
Purpose Many adult orthodontic patients suffer from periodontitis, which is caused by oral pathogens such as the gram-negative Aggregatibacter actinomycetemcomitans ( Agac ). Like orthodontic tooth movement, periodontitis is associated with inflammation and alveolar bone remodelling thereby affecting orthodontic treatment. Interactions of both processes, however, are not sufficiently explored, particularly with regard to oxidative stress. Methods After preincubation with Agac lysate for 24 h periodontal ligament fibroblasts (PDLF) were either stretched or compressed for further 48 h simulating orthodontic forces in vitro. We analysed the expression of genes and proteins involved in the formation of reactive oxygen species (NOX-4, ROS) and nitric oxide (NOS-2), inflammation ( TNF, IL-6, PTGS-2 ) and bone remodelling ( OPG, RANKL ). Results Agac lysate elevated the expression of NOX-4, NOS-2, inflammatory IL-6 and PTGS-2 and the bone-remodelling RANKL/OPG ratio during compressive, but not tensile mechanical strain. Agac lysate stimulated pressure-induced inflammatory signalling, whereas surprisingly ROS formation was reduced. Pressure-induced downregulation of OPG expression was inhibited by Agac lysate. Conclusions Agac lysate impact on the expression of genes and proteins involved in inflammation and bone remodelling as well as ROS formation, when PDLF were subjected to mechanical forces occurring during orthodontic tooth movement.
Article
Full-text available
Aim To assess the beneficial and adverse effects of periodontal-orthodontic treatment of teeth with pathological tooth flaring, drifting and elongation in patients with severe periodontitis on the dental and periodontal tissues. Materials and methods Nine databases were searched in April 2020 for randomized/non-randomized clinical studies. After duplicate study selection, data extraction, and risk-of-bias assessment, random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals (CIs) were performed, followed by subgroup/meta-regression analyses. Results A total of 30 randomized and non-randomized clinical studies including 914 patients (29.7% male; mean age 43.4 years) were identified. Orthodontic treatment of pathologically migrated teeth was associated with clinical attachment gain (-0.24 mm; 7 studies), pocket probing depth reduction (-0.23 mm; 7 studies), marginal bone gain (-0.36 mm; 7 studies), and papilla height gain (-1.42 mm; 2 studies), without considerable adverse effects, while patient sex, gingival phenotype, baseline disease severity, interval between periodontal-orthodontic treatment, and orthodontic treatment duration affected the results. Greater marginal bone level gains were seen by additional circumferential fiberotomy (2 studies; MD=-0.98 mm; 95% CI=-1.87 to -0.10 mm; P=0.03), but the quality of evidence was low. Conclusions Limited evidence of of poor quality indicates that orthodontic treatment might be associated with small improvements of periodontal parameters that don’t seem to affect long-term prognosis, but more research is needed.
Article
Full-text available
Objective: To investigate the association between orthodontic treatment and periodontitis in a nationally representative sample of South Korea. Materials and methods: Data from the Fifth and Sixth Korean National Health and Nutrition Examination Survey (KNHANES V, VI-1, and VI-2), conducted from 2012 to 2014, were used in this study. The final sample size consisted of 14,693 adults aged ≥19 years. Logistic regression analysis was performed to assess the association between orthodontic treatment and periodontitis. Results: The orthodontic treatment group exhibited a lower prevalence of periodontitis compared with the nonorthodontic treatment group. The adjusted odds ratios for periodontitis in subjects with a history of orthodontic treatment compared with those with no history of orthodontic treatment were 0.553, 0.614, and 0.624, when adjusted for various confounding variables (P < .0001). The subjects with periodontitis were of higher age, body mass index, waist circumference, and white blood cell counts compared with the subjects without periodontitis regardless of history of orthodontic treatment. Conclusions: History of orthodontic treatment was associated with a decreased rate of periodontitis.
Article
Full-text available
The aim is to evaluate the literature for clinical scientific data on possible effects of orthodontic treatment on periodontal status in periodontitis-susceptible subjects. A systematic literature review was performed on studies in English using PubMed, MEDLINE, and Cochrane Library central databases (1965-2014). By manually searching reference lists of selected studies, we identified additional articles; then we searched these publications: Journal of Periodontology, Periodontology 2000, Journal of Clinical Periodontology, American Journal of Orthodontics and Dentofacial Orthopedics, Angle Orthodontist, International Journal of Periodontics & Restorative Dentistry, and European Journal of Orthodontics. Search terms included randomized clinical trials, controlled clinical trials, prospective and retrospective clinical studies, case series >5 patients, periodontitis, orthodontics, alveolar bone loss, tooth migration, tooth movement, orthodontic extrusion, and orthodontic intrusion. Only studies on orthodontic treatment in periodontally compromised dentitions were included. One randomized controlled clinical trial, one controlled clinical trial, and 12 clinical studies were included. No evidence currently exists from controlled studies and randomized controlled clinical trials, which shows that orthodontic treatment improves or aggravates the status of periodontally compromised dentitions.
Article
Full-text available
The aim of this review is to describe the most commonly observed changes in periodontium caused by orthodontic treatment in order to facilitate specialists’ collaboration and communication. An electronic database search was carried out using PubMed abstract and citation database and bibliographic material was then used in order to find other appropriate sources. Soft and hard periodontal tissues changes during orthodontic treatment and maintenance of the patients are discussed in order to provide an exhaustive picture of the possible interactions between these two interwoven disciplines.
Article
Full-text available
Purpose: With the increasing prevalence of orthodontic treatment in adults, clear aligner treatments are becoming more popular. The aim of this study was to evaluate the effect of orthodontic treatment on periodontal tissue and to compare orthodontic treatment with fixed appliances (FA) to clear aligner treatment (CAT) in periodontitis patients. Methods: A total of 35 patients who underwent orthodontic treatment in the Department of Periodontology were included in this study. After periodontal treatment with meticulous oral hygiene education, patients underwent treatment with FA or CAT, and this study analyzed patient outcomes depending on the treatment strategy. Clinical parameters were assessed at baseline and after orthodontic treatment, and the duration of treatment was compared between these two groups. Results: The overall plaque index, the gingival index, and probing depth improved after orthodontic treatment (P<0.01). The overall bone level also improved (P=0.045). However, the bone level changes in the FA and CAT groups were not significantly different. Significant differences were found between the FA and CAT groups in probing depth, change in probing depth, and duration of treatment (P<0.05). However, no significant differences were found between the FA and CAT groups regarding the plaque index, changes in the plaque index, the gingival index, changes in the gingival index, or changes in the alveolar bone level. The percentage of females in the CAT group (88%) was significantly greater than in the FA group (37%) (P<0.01). Conclusions: After orthodontic treatment, clinical parameters were improved in the FA and CAT groups with meticulous oral hygiene education and plaque control. Regarding plaque index and gingival index, no significant differences were found between these two groups. We suggest that combined periodontal and orthodontic treatment can improve patients' periodontal health irrespective of orthodontic techniques.
Article
Full-text available
The scope of orthodontics has widened to include not only children and adolescents but also adults, thereby abolishing the upper age limit. With growing esthetic conscience among the society, a great number of young adults are seeking orthodontic treatment primarily for esthetic reasons. They undergo comprehensive orthodontic treatment involving major occlusal changes to get the utmost esthetically pleasing face. The older adults with poor dental conditions requiring perio-restorative treatment undergo adjunctive orthodontic treatment to attain a long-term prognosis. The orthodontist faces challenges to practice adult orthodontics due to various issues being under considerations, which are quite different than routine orthodontic treatment oriented to children and adolescents. This article highlights the difficulties and limitations faced by the orthodontist while practicing adult orthodontics with remedies to overcome them.
Article
Objectives This review provides a comprehensive assessment of the benefits of adjunctive orthodontic treatment with or without periodontal regenerative surgery in the treatment of angular bony defects, defect volume, and periodontal tissue conditions in adult patients. Methods An electronic keyword search was conducted in the literature database PubMed as well as in Google Scholar. Originally, studies describing all types of orthodontic tooth movement (tipping, bodily movement, intrusion, extrusion) in relation to bone defects such as periodontal, furcation and extraction site defects were reviewed. Only those articles depicting tooth movement after periodontal therapy and the control of inflammation were included. Results Evidence indicates that orthodontic tooth movement can result in the reduction or elimination of periodontal bony defect dimensions, a reduction in probing pocket depth and a gain in clinical attachment level. Furthermore, the published data show that orthodontic tooth movement before or after regenerative surgery can provide therapeutic benefits in the recovery of angular bony defects. Conclusions This review supports the premise that adjunctive orthodontic treatment in adults with reduced but healthy periodontal tissues is a solution for the modification of bony defect contours with or without periodontal regenerative therapy.
Article
Aim: To compare two treatment strategies regarding the effect of orthodontic treatment on periodontal status in patients with plaque-induced periodontitis. Subjects and methods: This was a randomised clinical trial. Fifty periodontal patients were randomly assigned to the test or control groups according to periodontal treatment timing. All patients received supra- and sub-gingival debridement following baseline examination. Control group patients received cause-related periodontal treatment before the start of orthodontic treatment and which was performed simultaneous to orthodontic treatment for the test group patients. Results: No difference between the test and control groups was found regarding change of clinical attachment level (CAL) after periodontal-orthodontic treatment. Fewer sites with initial pocket depth (PD) of 4-6 mm healed after periodontal-orthodontic treatment in the test group (20.5%, IQR=11.9%) in comparison with controls (30.4%, IQR=27.1%) (p=0.03). Anterior teeth [OR 2.5] and teeth in male patients [OR 1.6] had a greater chance for PD improvement ≥2mm. Total periodontal-orthodontic treatment duration was significantly longer for the control group (p<0.01). Conclusions: Both groups showed a gain of CAL and a reduction of sites with PD ≥ 4mm. Orthodontic treatment, simultaneously to the periodontal treatment, could be used in the routine treatment of patients with plaque-induced periodontitis. This article is protected by copyright. All rights reserved.
Article
Aim: To assess the prevalence and severity of periodontal conditions among a representative sample of employed adults in Spain. Material and methods: A national cross-sectional study was conducted during 2008-2011. Periodontal status of 5,130 workers, stratified by gender, age and occupation, was assessed based on Community Periodontal Index (CPI) and Clinical Attachment Level (CAL), following the WHO criteria. Results: The percentage of subjects with periodontal pockets (CPI codes 3-4) was 38.4% (95% Confidence Interval [CI]: 36.4-40.5) increasing significantly in subjects ≥45 years. 13.7% (95% CI: 12.8-14.7) of workers showed CAL 4-5 mm, while 7.7% (95% CI: 7.0-8.5) showed CAL ≥6 mm, again increasing significantly in the population ≥45 years. Prevalence of worse periodontal conditions was significantly higher in male workers, primary school education, lower income and smokers and former smokers. The periodontal condition in young adults (35-44 years) was worse in comparison with those previously reported in Spanish national surveys. Conclusion: Prevalence of destructive periodontal diseases was age, gender, education, income and tobacco smoking-related. Young adults showed worse periodontal conditions than it has been previously reported in national surveys in Spain. It is suggested to include oral evaluation and preventive strategies in work-related medical check-ups. This article is protected by copyright. All rights reserved.
Article
There is an ever increasing concern for dentofacial esthetics in adult population. The primary motivating factor for seeking orthodontic treatment is dental appearance [1]. Pathologic migration of anterior teeth is a common cause of esthetic concern among adults. Pathologic migration is defined as change in tooth position resulting from disruption of the forces that maintain teeth in normal position in relation to their arch. The disruption of equilibrium in tooth position may be caused by several etiologic factors. These include periodontal attachment loss, pressure from inflamed tissues, occlusal factors, oral habits such as tongue thrusting and bruxism, loss of teeth without replacement, gingival enlargement and iatrogenic factors. However, according to the literature, destruction of tooth supporting structures is the most relevant factor associated with pathologic migration. Periodontal disease in the upper anterior region can be in isolation or may affect more teeth. The periodontal disease and its sequale such as diastema, pathological migration, labial tipping or missing teeth often lead to functional and esthetic problems either alone or with restorative problems [2]. Advanced periodontal disease is characterized by severe attachment loss, reduced alveolar bone support, tooth mobility and gingival recession. Orthodontic treatment is initiated only after periodontal disease is brought under control [3]. This communication highlights good treatment outcome achieved in a patient with impaired dentofacial aesthetics and advanced periodontal disease.